The factors of perceived disease knowledge and self-care behavior in type 2 diabetic patients with chronic kidney disease: A cross-sectional study.

Chronic kidney diseases (CKD) is an important public health issue worldwide, and diabetes mellitus is the main cause of CKD. Having sufficient disease knowledge and good self-care behavior both help to prevent the progression of diabetes mellitus and CKD. This cross-sectional study enrolled 181 type 2 diabetic patients with CKD from July 2017 to October 2017. Perceived Kidney Knowledge survey and structured questionnaires of self-care behavior were used to measure perceived disease knowledge and CKD Self-Care (CKDSC) scales respectively with the determinants analyzed by linear regression. Meanwhile, socio-demographic information, kidney function and laboratory data were collected. Of 181 enrolled patients, the mean age was 66.8 ±â€…9.7 years, 59.1% were male and the mean estimated glomerular filtration rate was 33.1 ±â€…23.1 mL/min/1.73 m2. The mean scores of CKDSC and perceived disease knowledge were 63.2 and 22.4, respectively. High scores of disease knowledge were significantly correlated with low glycated hemoglobin (P = .03) and high scores of overall self-care behavior (P = .03) and aspects of self-care behavior, including diet (P = .003), exercise (P = .02), and home blood pressure monitoring (P = .04). The relationship between young age and high scores of disease knowledge was found (P = .001); however, old age was significantly associated with high scores of overall self-care behavior (P < .001) while additionally, married patients had high scores of regular medication behavior (P = .03). Our findings identified the significant factors correlated with disease knowledge and self-care behavior in type 2 diabetic patients with CKD. Healthcare givers should establish personalized health education plans to improve perceived disease knowledge and self-care behavior.

Shared decision-making for renal replacement treatment and illness perception in patients with advanced chronic kidney disease.

BACKGROUND: Current healthcare trends emphasize the use of shared decision-making (SDM) for renal replacement treatment (RRT) in patients with chronic kidney disease (CKD). This is crucial to understand the relationship between SDM and illness perception of CKD patients. Few studies have focused on SDM and illness perception status of CKD patients and the impact of illness perception on RRT after SDM. METHODS: In this cross-sectional study, we used a questionnaire with purposive sampling from March 2019 to February 2020 at the nephrology outpatient department of a medical center in southern Taiwan. The nephrology medical team in this study used the SHARE five-step model of SDM to communicate with the patients about RRT and Brief Illness Perception Questionnaire (BIPQ) was applied to evaluate illness perception of these patients at the beginning of SDM. According to the SDM decision time, the study participants were classified general and delayed SDM groups. The distribution between SDM groups was estimated using independent two sample t-test, chi-squared test or Fisher's exact test. The correlation between illness perception and SDM decision time were illustrated and evaluated using Spearman's correlation test. A p-value less than 0.05 is statistically significant. RESULTS: A total of 75 patients were enrolled in this study. The average time to make a dialysis decision after initiating SDM was 166.2 ± 178.1 days. 51 patients were classified as general group, and 24 patients were classified as delayed group. The median SDM decision time of delayed group were significantly longer than general group (56 vs. 361 days, P < 0.001). Our findings revealed that delayed group was significantly characterized with not created early surgical assess (delayed vs. general: 66.7% vs. 27.5%, p = 0.001) compared to general group. The average BIPQ score was 54.0 ± 8.1 in our study. We classified the patients into high and low illness perception group according to the median score of BIPQ. The total score of BIPQ in overall participants might increase by the SDM decision time (rho = 0.83, p = 0.830) and the linear regression line also showed consistent trends between BIPQ and SDM decision time in correspond cohorts. However, no statistically significant findings were found. CONCLUSIONS: The patients with advanced chronic kidney disease took an average of five and a half months to make a RRT decision after undergoing SDM. Although there is no statistical significance, the trend of illness perception seems correlated with decision-making time. The stronger the illness perception, the longer the decision-making time. Furthermore, shorter decision times may be associated with earlier establishment of surgical access. We need more research exploring the relationship between illness perception and SDM for RRT in CKD patients.

Mobile Health, Disease Knowledge, and Self-Care Behavior in Chronic Kidney Disease: A Prospective Cohort Study.

Mobile health (mHealth) management is an emerging strategy of care for patients with chronic diseases. However, the effect of mHealth management on clinical outcomes of patients with chronic kidney disease (CKD) has not been well-studied. The aim of this study was to investigate the additional influence of mHealth on disease knowledge and self-care behavior in CKD patients who had received traditional education. We designed and developed a new healthcare mobile application, called iCKD, which has several major features, including home-based physiological signal monitoring, disease health education, nutrition analysis, medication reminder, and alarms and a warning system. Trained nurses interviewed patients with CKD using structured questionnaires of disease knowledge and self-care behavior. After propensity score matching, we analyzed 107 patients who used iCKD and traditional education, and 107 who received traditional education. The patients who used iCKD had higher disease knowledge scores than those who received traditional education. In multivariate analysis, iCKD was significantly and positively associated with disease knowledge scores. Patients with high education levels could have greater disease knowledge through using mHealth. There was no significant difference in total scores of self-care behavior between the two groups. In conclusion, mHealth can significantly increase disease knowledge in patients with CKD.

The Relationship between Subtypes of Health Literacy and Self-Care Behavior in Chronic Kidney Disease.

Chronic kidney disease (CKD) is a global public health issue that is associated with high rates of morbidity and mortality. Self-care behavior has been associated with clinical outcomes in chronic diseases, and adequate self-care behavior may mitigate adverse outcomes. Health literacy may be an important factor associated with self-care. The aim of this study was to examine the relationships between different domains of self-care behavior and health literacy in patients with CKD. This study enrolled 208 patients with CKD stages 1-5 who were not undergoing renal replacement therapy at Kaohsiung Medical University Hospital from April 2019 to January 2020. Health literacy was measured using a multidimensional health literacy questionnaire covering the following five dimensions: accessing, understanding, appraising, and applying health information, and communication/interaction. The CKD Self-Care scale, which is a 16-item questionnaire with five domains including medication adherence, diet control, exercise, smoking behavior, and home blood pressure monitoring was used to assess self-care behavior. Among the 208 patients, 97 had sufficient or excellent health literacy, and 111 had inadequate or limited/problematic health literacy. A higher health literacy score was significantly correlated with greater self-care behavior. Among the five domains of self-care behavior, the patients who had sufficient or excellent health literacy had higher diet, exercise, and home blood pressure monitoring scores than those who had inadequate or limited/problematic health literacy. This study demonstrated that health literacy was significantly and positively correlated with self-care behavior in patients with CKD.

The interaction between self-care behavior and disease knowledge on the decline in renal function in chronic kidney disease.

Multidisciplinary care can improve the outcomes of chronic kidney disease (CKD), however the contribution of self-care behavior and knowledge about CKD is unclear. This study enrolled 454 participants with CKD stages 1-5 not on dialysis. Structured questionnaires were used to evaluate self-care behavior and kidney disease knowledge. Rapid decline in renal function was defined as the decline in estimated filtration rate > 3 ml/min per 1.73 m2/year within 1-year prior to enrollment. The mean age of all study participants was 65.8 ± 12.1 years and 55.9% were male. The elderly had better self-care behavior while younger participants had better disease knowledge. Both high self-care and high disease knowledge scores were significantly associated with and had a synergistic effect on decreasing the risk of rapid decline in renal function. CKD patients with better self-care behavior and better kidney disease knowledge had lower risk of rapid decline in renal function.

[Project to Increase the Usage Rate of iCKD Application Mobile Healthcare on Chronic Kidney Disease Patients].

BACKGROUND & PROBLEMS: In recent years, improved mobile capacities and mobile-device computing capabilities as well as a maturing mobile-communications infrastructure have combined to promote the development and widespread use of mobile healthcare applications. Mobile healthcare supports the self-management of chronic diseases, enhances healthcare quality, and reduces medical costs. Due to the low rate of iCKD usage in our hospital, we set up a project team that was tasked to improve the rate of iCKD usage among chronic disease patients. PURPOSE: To improve the iCKD usage rate from the current 5.8% to 9.3%. RESOLUTIONS: Questionnaire-based survey results indicated that the main reasons for the low iCKD usage rate in our hospital were: negative attitudes toward iCKD as a helpful tool in disease management, lack of awareness of the importance of using iCKD, unfamiliarity with how to operate smartphone applications, low numbers of iCKD physician referrals for patients, and slow Internet speeds. The improvement strategy included providing instructions on iCKD use, organizing a practical learning program, designing and printing a mobile healthcare referral form, and holding related events. RESULTS: The rate of iCKD usage increased to 21.3% after the intervention. CONCLUSIONS: The project team successfully increased the iCKD usage rate by getting more patients involved in mobile healthcare, which is expected to have a positive impact on the success of patient self-management.

Patient assessment of chronic kidney disease self-care using the chronic kidney disease self-care scale in Taiwan.

AIM: Self-care represents the 'action' element of self-management. This study aimed to use the chronic kidney disease self-care (CKDSC) scale to examine factors associated with self-care and aspects of self-care deficits among CKD patients in Taiwan. METHODS: A cross-sectional investigation was conducted using the CKDSC scale with 449 CKD patients in Taiwan. The CKDSC is a 16-item questionnaire with five subscales, including medication adherence, diet control, exercise, smoking behaviours and blood pressure monitoring. Patient demographic and clinical factors taht may affect CKD self-care were analyzed in the multivariable regression models. RESULTS: Overall CKDSC scores were significantly higher for women (P = 0.020), older patients (P < 0.001), higher education (P = 0.033), BMI <24 kg/m2 (P = 0.005), later CKD stage or participants in the CKD care programme. Early-stage CKD patients had significantly lower for medication adherence, diet control, and blood pressure monitoring. Patients who participated in the CKD care programme had higher for medication adherence, diet control and regular exercise habits. CONCLUSION: The CKDSC scale is a tool to assess patient self-care. However, given the CKDSC tool is in Chinese, future studies should validate it in CKD patients in other languages or countries before it can be considered for general use.

The interaction between N-terminal pro-brain natriuretic peptide and fluid status in adverse clinical outcomes of late stages of chronic kidney disease.

INTRODUCTION: Fluid overload is one of the major characteristics and complications in patients with chronic kidney disease (CKD). N-terminal pro-brain natriuretic peptide (NT-proBNP) is related to fluid status and fluid distribution. The aim of this study is to investigate the interaction between NT-proBNP and fluid status in adverse clinical outcomes of late stages of CKD. METHODS: We enrolled 239 patients with CKD stages 4-5 from January 2011 to December 2011 and followed up until June 2017. Fluid status was presented as hydration status (HS) value measured by body composition monitor, while HS>7% was defined as fluid overload. Clinical outcomes included renal outcomes (commencing dialysis and estimated glomerular filtration rate decline>3 ml/min/1.73 m2/year), all-cause mortality and major adverse cardiovascular events (MACEs). RESULTS: During a mean follow-up of 3.3±2.0 years, 129(54.7%) patients commenced dialysis, 88(37.3%) patients presented rapid renal function decline, and 48(20.3%) had MACEs or died. All patients were stratified by HS of 7% and the median of plasma NT-proBNP. The adjusted risks for commencing dialysis was significantly higher in patients with high plasma NT-proBNP and HS>7% compared to those with low plasma NT-proBNP and HS≦7%. There was a significant interaction between plasma NT-proBNP and HS in commencing dialysis (P-interaction = 0.047). Besides, patients with high plasma NT-proBNP and HS>7% had greater risks for MACEs or all-cause mortality than others with either high plasma NT-proBNP or HS>7%. CONCLUSION: NT-proBNP and fluid overload might have a synergistic association of adverse clinical outcomes in patients with late stages of CKD.

The interaction between fluid status and angiopoietin-2 in adverse renal outcomes of chronic kidney disease.

BACKGROUND: Fluid overload is not only the characteristic but also an important complication in chronic kidney disease (CKD) patients. Angiopoietin-2 (Angpt2) disturbs endothelium and vessel permeability, which may induce fluid overload. The aim of this study is to examine the interaction between fluid status and Angpt2 in adverse renal outcomes of CKD. METHODS: This cohort study enrolled 290 patients with CKD stages 3-5 from January 2011 to December 2011 and followed up until December 2015. Fluid status was presented as overhydration (OH) value measured by body composition monitor, while OH>1.1L was defined as fluid overload. Renal outcomes were defined as commencing dialysis and rapid renal function decline (the slope of estimated glomerular filtration rate < -5 ml/min/1.73 m2/y). RESULTS: During a mean follow-up of 38.6±18.3 months, 125 (43.1%) patients progressed to commencing dialysis and 99(34.7%) patients presented rapid renal function decline. All patients were stratified by OH of 1.1L and the median of circulating Angpt2. These patients with both OH>1.1L and high circulating Angpt2 were more likely to reach commencing dialysis compared to other groups. The risks for commencing dialysis and rapid renal function decline were significantly higher in patients with OH>1.1L and high circulating Angpt2 level compared to those with OH≦1.1L and low circulating Angpt2 (2.14, 1.21-3.78, P = 0.009; 4.96, 1.45-16.97, P = 0.01). There was a significant interaction between OH level and circulating Angpt2 in entering dialysis (P-interaction = 0.02). CONCLUSIONS: Fluid overload and Angpt2 might have a synergistic effect on adverse renal outcomes in CKD patients.

Association of Fluid Status and Body Composition with Physical Function in Patients with Chronic Kidney Disease.

BACKGROUND: Impairment of physical function and abnormal body composition are the major presentations in patients with chronic kidney disease (CKD). The aim of this study is to investigate the relationship between body composition and physical function in CKD patients. METHODS: This cross-sectional study enrolled 172 of CKD stages 1-5 from February 2013 to September 2013. Handgrip strength (upper extremity muscle endurance), 30-second chair-stand test (lower extremity muscle endurance) and 2-minute step test (cardiorespiratory endurance) were used as indices of physical function. Body composition, including fluid status (extracellular water/total body water, ECW/TBW), lean tissue index (LTI), and fat tissue index (FTI), was measured using a bioimpedance spectroscopy method. RESULTS: All patients with high ECW/TBW had lower handgrip strength and 30-second chair-stand than those with low ECW/TBW (P<0.001 and P = 0.002). CKD patients with high FTI had lower handgrip strength and 30-second chair-stand than those with low FTI (P<0.001 and P = 0.002). These patients with low LTI had lower handgrip strength than those with high LTI (P = 0.04). In multivariate analysis, high ECW/TBW was positively associated with decreased handgrip strength (ß = -41.17, P = 0.03) in CKD patients. High FTI was significantly correlated with decreased times of 30-second chair-stand (ß = -0.13, P = 0.01). There was no significant relationship between body composition and 2-minute step test. CONCLUSIONS: Our results show a significant association of impaired upper and lower extremity muscle endurance with high fluid status and fat tissue. Evaluation of body composition may assist in indentifying physical dysfunction earlier in CKD patients.

[Construction and Validation of a Chronic Kidney Disease Self-Care Scale].

BACKGROUND: As the prevalence of chronic kidney disease (CKD) increases, it is important to understand the self-care behavior of CKD patients. OBJECTIVES: To construct a CKD self-care scale and evaluate its metric properties. METHODS: Through literature review and clinical experience, question items were constructed and validated using item analysis. Factors analysis was used to validate the reliability and validity of the resultant questionnaire in a cross-sectional study. RESULTS: Six subscales containing a total of 20 items were extracted from the original CKD self-care scale using item and exploratory factor analysis. After performing three-time model goodness of fit, only five subscales including regular medication (5 items), diet control (4 items), regular exercise (3 items), smoking habits (2 items), and blood pressure management (2 items) were included in the final scale. The total explained variance of the final subscales was 74.96%. The reliability of the scale was examined and found to be satisfactory. Each absolute factor loading value fell between .72 and .94. The Cronbach's alpha for the overall scale was .83 and those for the five subscales were .83, .83, .94, .81, and .87, respectively. CONCLUSIONS / IMPLICATIONS FOR PRACTICE: Appropriate assessment tools that allow CKD health educators to evaluate the self-care behaviors of patients effectively are needed. The valid and reliable CKD self-care scale that was developed in the present study is able to assist CKD health educators to quickly evaluate the self-care behavior of patients and to make appropriate health plans.

Association of fluid overload with cardiovascular morbidity and all-cause mortality in stages 4 and 5 CKD.

BACKGROUND AND OBJECTIVES: Fluid overload is a common characteristic associated with renal progression in CKD. Additionally, fluid overload is an independent predictor of all-cause or cardiovascular mortality in patients on dialysis, but its influence on patients not on dialysis is uncertain. The aim of the study was to assess the relationship between the severity of fluid status and clinical outcomes in an advanced CKD cohort. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In total, 478 predialysis patients with stages 4 and 5 CKD in the integrated CKD care program were enrolled from January of 2011 to December of 2011 and followed-up until August of 2013. The clinical outcomes included cardiovascular morbidity and all-cause mortality. The relative hydration status (overhydration/extracellular water) was used as the presentation of the severity of fluid status and measured using a body composition monitor. Overhydration/extracellular water >7% was defined as fluid overload. RESULTS: Over a median follow-up period of 23.2 (12.6-26.4) months, 66 (13.8%) patients reached all-cause mortality or cardiovascular morbidity. The adjusted hazard ratio of the combined outcome of all-cause mortality or cardiovascular morbidity for every 1% higher overhydration/extracellular water was 1.08 (95% confidence interval, 1.04 to 1.12; P<0.001). The adjusted overhydration/extracellular water for the combined outcome of all-cause mortality or cardiovascular morbidity in participants with overhydration/extracellular water ≥7% compared with those with overhydration/extracellular water <7% was 1.93 (95% confidence interval, 1.01 to 3.69; P=0.04). In subgroup analysis, higher overhydration/extracellular water was consistently associated with increased risk for the combined outcome independent of diabetes, cardiovascular disease, and serum albumin. There was no significant interaction between all subgroups. CONCLUSIONS: These findings suggest that fluid overload is an independent risk factor of the combined outcome of all-cause mortality or cardiovascular morbidity in patients with advanced CKD.

Fluid overload, pulse wave velocity, and ratio of brachial pre-ejection period to ejection time in diabetic and non-diabetic chronic kidney disease.

Fluid overload is one of the characteristics in chronic kidney disease (CKD). Changes in extracellular fluid volume are associated with progression of diabetic nephropathy. Not only diabetes but also fluid overload is associated with cardiovascular risk factors The aim of the study was to assess the interaction between fluid overload, diabetes, and cardiovascular risk factors, including arterial stiffness and left ventricular function in 480 patients with stages 4-5 CKD. Fluid status was determined by bioimpedance spectroscopy method, Body Composition Monitor. Brachial-ankle pulse wave velocity (baPWV), as a good parameter of arterial stiffness, and brachial pre-ejection period (bPEP)/brachial ejection time (bET), correlated with impaired left ventricular function were measured by ankle-brachial index (ABI)-form device. Of all patients, 207 (43.9%) were diabetic and 240 (50%) had fluid overload. For non-diabetic CKD, fluid overload was associated with being female (ß = -2.87, P = 0.003), heart disease (ß = 2.69, P = 0.04), high baPWV (ß = 0.27, P = 0.04), low hemoglobin (ß = -1.10, P < 0.001), and low serum albumin (ß = -5.21, P < 0.001) in multivariate analysis. For diabetic CKD, fluid overload was associated with diuretics use (ß = 3.69, P = 0.003), high mean arterial pressure (ß = 0.14, P = 0.01), low bPEP/ET (ß = -0.19, P = 0.03), low hemoglobin (ß = -1.55, P = 0.001), and low serum albumin (ß = -9.46, P < 0.001). In conclusion, baPWV is associated with fluid overload in non-diabetic CKD and bPEP/bET is associated with fluid overload in diabetic CKD. Early and accurate assessment of these associated cardiovascular risk factors may improve the effects of entire care in late CKD.

Modification of diet in renal disease (MDRD) study and CKD epidemiology collaboration (CKD-EPI) equations for Taiwanese adults.

BACKGROUND: Estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease (MDRD) study or the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations may not be accurate for Asians; thus, we developed modified eGFR equations for Taiwanese adults. METHODS: This cross-sectional study compared the Taiwanese eGFR equations, the MDRD study, and the CKD-EPI equations with inulin clearance (Cin). A total of 695 adults including 259 healthy volunteers and 436 CKD patients were recruited. Participants from the Kaohsiung Medical University Hospital were used as the development set (N = 556) to develop the Taiwanese eGFR equations, whereas participants from the National Taiwan University Hospital were used as the validation set (N = 139) for external validation. RESULTS: The Taiwanese eGFR equations were developed by using the extended Bland-Altman plot in the development set. The Taiwanese MDRD equation was 1.309 × MDRD0.912, Taiwanese CKD-EPI was 1.262×CKD-EPI0.914 and Taiwanese four-level CKD-EPI was 1.205 × four-level CKD-EPI0.914. In the validation set, the Taiwanese equations had the lowest bias, the Taiwanese equations and the Japanese CKD-EPI equation had the lowest RMSE, whereas the Taiwanese and the Japanese equations had the best precision and the highest P30 among all equations. However, the Taiwanese MDRD equation had higher concordance correlation than did the Taiwanese CKD-EPI, the Taiwanese four-level CKD-EPI and the Japanese equations. Moreover, only the Taiwanese equations had no proportional bias among all of the equations. Finally, the Taiwanese MDRD equation had the best diagnostic performance in terms of ordinal logistic regression among all of the equations. CONCLUSION: The Taiwanese MDRD equation is better than the MDRD, CKD-EPI, Japanese, Asian, Thai, Taiwanese CKD-EPI, and Taiwanese four-level CKD-EPI equations for Taiwanese adults.

A novel TLR2-triggered signalling crosstalk synergistically intensifies TNF-mediated IL-6 induction.

Toll-like receptors (TLR) recognize pathogens and trigger the production of vigorous pro-inflammatory cytokines [such as tumour necrosis factor (TNF)] that induce systemic damages associated with sepsis and chronic inflammation. Cooperation between signals of TLR and TNF receptor has been demonstrated through the participation of TNF receptor 1 (TNFR) adaptors in endotoxin tolerance. Here, we identify a TLR2-mediated synergy, through a MyD88-independent crosstalk, which enhances subsequent TNF-mediated nuclear factor-kappa B activation and interleukin-6 induction. Membrane-associated adaptor MAL conduces the link between TNF receptor-associated factor 6 (TRAF6) and TNFR-associated death domain, leading to a distinctive K63-ubiquitinylated TRAF6 recruitment into TNFR complex. In summary, our results reveal a novel route of TLR signal that synergistically amplifies TNF-mediated responses, indicating an innovative target for inflammation manipulation.

Association of fluid overload with kidney disease progression in advanced CKD: a prospective cohort study.

BACKGROUND: Fluid overload is a common phenomenon in patients in a late stage of chronic kidney disease (CKD). However, little is known about whether fluid overload is related to kidney disease progression in patients with CKD. Accordingly, the aim of the study was to assess the association of the severity of fluid status and kidney disease progression in an advanced CKD cohort. STUDY DESIGN: Prospective observational cohort study. SETTING & PARTICIPANTS: This cohort study enrolled 472 non-dialysis-dependent patients with CKD stages 4-5 who were in an integrated CKD care program from January 2011 to December 2011 and followed up until December 2012 or initiation of renal replacement therapy (RRT). PREDICTORS: Tertile of fluid overload, with cutoff values at 0.6 and 1.6 L. OUTCOMES: RRT, rapid estimated glomerular filtration rate (eGFR) decline (faster than 3 mL/min/1.73 m(2) per year), and change in eGFR. MEASUREMENTS: The severity of fluid overload was measured by a bioimpedance spectroscopy method. eGFR was computed using the 4-variable MDRD (Modification of Diet in Renal Disease) Study equation. RESULTS: During a median 17.3-month follow-up, 71 (15.0%) patients initiated RRT and 187 (39.6%) experienced rapid eGFR decline. The severity of fluid overload was associated with increased risk of RRT (tertile 3 vs tertile 1: adjusted HR, 3.16 [95% CI, 1.33-7.50]). Fluid overload value was associated with increased risk of rapid eGFR decline (tertile 3 vs tertile 1: adjusted OR, 4.68 [95% CI, 2.30-9.52]). Furthermore, the linear mixed-effects model showed that the reduction in eGFR over time was faster in tertile 3 than in tertile 1 (P=0.02). LIMITATIONS: The effect of fluid volume variation over time must be considered. CONCLUSIONS: Fluid overload is an independent risk factor associated with initiation of RRT and rapid eGFR decline in patients with advanced CKD.

Is fluid overload more important than diabetes in renal progression in late chronic kidney disease?

Fluid overload is one of the major presentations in patients with late stage chronic kidney disease (CKD). Diabetes is the leading cause of renal failure, and progression of diabetic nephropathy has been associated with changes in extracellular fluid volume. The aim of the study was to assess the association of fluid overload and diabetes in commencing dialysis and rapid renal function decline (the slope of estimated glomerular filtration rate (eGFR) less than -3 ml/min per 1.73 m(2)/y) in 472 patients with stages 4-5 CKD. Fluid status was determined by bioimpedance spectroscopy method, Body Composition Monitor. The study population was further classified into four groups according to the median of relative hydration status (△HS =fluid overload/extracellular water) and the presence or absence of diabetes. The median level of relative hydration status was 7%. Among all patients, 207(43.9 %) were diabetic. 71 (15.0%) subjects had commencing dialysis, and 187 (39.6%) subjects presented rapid renal function decline during a median 17.3-month follow-up. Patients with fluid overload had a significantly increased risk for commencing dialysis and renal function decline independent of the presence or absence of diabetes. No significantly increased risk for renal progression was found between diabetes and non-diabetes in late CKD without fluid overload. In conclusion, fluid overload has a higher predictive value of an elevated risk for renal progression than diabetes in late CKD.